izr - 



LIBRARY OF CONGRESS: 



(SMITHSONIAN DEPOSIT.) 

Chap. "KC \^* 



UNITED STATES OF AMERICA, 



ORIGINAL INVESTIGATIONS 



IN 



DIPHTHERIA AND SCARLET 

FEVER, 

SHOWING THEIR KINSHIP AND CAUSE TO BE THE 

MUCOR -MALIGNANS, 

(A Fungus in the Exudations, Blood, Urine and Sputa,) 



CURED BY QUININE TOPICALLY ADMINISTERED IN POWDER ON THE TONGUE, 

AND B Y INHALA TION 



BY 

JAMES H. SALISBURY, B. N. S., A.M., M. D., 

MkMBER PHILOSOPHICAL SOCIETY OF GREAT BRITAIN, OF AMERICAN ANTIQUARIAN SOCIETY, AMERICAN ASSOCIATION FOR THE 

ADVANC MFNT OF SCIENCE, VICE-PRESIDENT WESTERN RESERVE HISTORICAL SOCIETY, AUTHOR PRIZE ESSAY ON 

MALARIA, 1882, AND OF PUBLISHED AND UNPUBLISHED WORKS AND PAPERS. 



/ V ' 



>F PUBLISHED AND UNP 

NOV 7 1882 ) 



All rights reserved. Reprint Gai/lard's Medical Journal, May, 1882. 



NEW YORK : 

E. S. GAILLARD, 

1882. 
















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\ 



\p 



DlPHTHEEIA AND SCARLET FEYER. 



{Reprinted from " Gaillard's Medical Journal") 



DlPHTHEEIA AND SCAELET FEVEE, BY 

James H/ Salisbury, B. N. S., A. 
M., M. D., New York : 1882. {All 
rights reserved.) 



Microscopical investigations con- 
nected with the exudation and expec- 
toration of angina membranacea, an- 
gina maligna or gangrenosa, and scarla- 
tina anginosa; resulting in the discov- 
ery of the source of and the patholo- 
gical process by which the exudations 
are produced, and the further discov- 
ery of a peculiar species of Mucor 
developing in the diphtheritic mem- 
branes of angina maligna and which 
appears to be the true cause of the 
disease ; with some remarks on 



treatment. 

Also some general conclusions on 
the setiology of fevers; the peculiar 
functions of the epithelial systemic 
cell envelope; and the probable way 

in which the system receives a more plow their soilj for put ting in the winter 
or less permanent protective immu- wheat. The grasses of pastures and mead, 
nity, by one attack of certain conta- ws were parched, dry, and mostly dead; 
gious diseases against a second inva- and the herbaceous plants of the fields and 



that there is a tendency also for the lining 
membranes of the genital organs, intestines 
and bladder, and in short the epithelial cells 
of the entire mucous surface to take on the 
diphtheritic action. This renders it evi- 
dent that this disease, like scarlatina angi- 
nosa, (which it will be shown to resemble) 
is systemic,with a marked tendency to local- 
ization in the respiratory tract. 

Angina maligna, in its worst form, ac- 
companied by angina membranacea,became 
epidemic during the months of October, 
November and December of the year 1862, 
and January and February, 1863, over a 
tract of country, about five miles long from 
north-west to south-east, and three miles 
wide, situated from two and a half to five 
miles south-west and west of the city of 
Lancaster, Ohio. 

It first appeared immediately after a snow 
storm (the first of the season in October). 
The snow fell about two inches deep, upon 
a remarkably dry, parched soil, and was the 
beginning of the fall wet weather, after a 
long period of drought, which was so severe 
that it was impossible for the farmers to 



sion of the same. 

M.Bretonneau gave to angina membranacea 
the name of diphtheritis, on account of the 
pellicle-like exudations. The ordinary sites 
of these exudations, as is well known, are 
the fauces and pharynx; often however they 
extend past the pharyngeal and laryngeal 
regions far down the oesophagus, and into 
the trachea and bronchial tubes, and even 
upward into the nasal fossae. 

Microscopic examinations show, further, 



forests were in the same condition. The 
disease first made its appearance at the 
south-east end of the section before describ- 
ed, among the dry sandy hills, and gradu- 
ally progressed to the north-west. ' It ex- 
hibited, often in the same family, all grades 
of severity from a mild type of angina mem- 
branacea to the most severe form of angina 
maligna-, where the extremities would be- 
come gangrenous, in some cases, several 
days before death. The malignant form 



401 



402 



DIPHTHERIA AND SCARLET REFER. 



was unusually fatal and rapid in its pro- 
gress; often from two to five persons dying 
in a single family, within a few days of each 
other. The young became the victims; 
while those above twenty-five usually es- 
caped. 

The section over which this malignant 
disease prevailed, composed of hills and 
high table lands, is abundantly supplied 
with fine springs of cold, free stone water, 
and is regarded as a particularly' healthy 
region. It is inhabited mostly by sober, 
industrious German farmers. 

An excellent opportunity was here of- 
fered for studying the disease. Through 
the kindness of Doctors Effinger, Boerstler 
and Lewis I was able to obtain the best of 
material for examination. 

From its progress in this region, from 
family to family, and from other circum- 
stances,hereafter mentioned,there appeared 
to be no doubt of its contagious character. 
The period of incubation ranged,in different 
cases, from three to six and eight days; un- 
less, accidentally, the air passages became 
directly inoculated with the virus or vege- 
tation, in which case, the disease would 
begin to show itself immediately. 

The cases could be nearly all traced to 
exposure to the contagion of the disease. 
When it once made its appearance in a 
family, any of the younger members seldom 
escaped. 

Before entering upon a description of the 
following cases, and the microscopic exam- 
inations of the exudations, etc., I will 
briefly narrate the characters of angina 
membranacea and angina maligna, set 
forth by Dr. Tweedie; as his remarks upon 
these diseases, in several important partic- 
ulars, point in the direction of the results 
of these investigations. 

In speaking of angina membranacea, he 
says: "The patches are of various extent; 
in mild cases, white and ashy, separate, and 
presenting the appearance of superficial 
sloughs, for which they have often been 
mistaken; in others, dark colored, coales- 
cent, and forming one uniform crust. 
TJle exudations may extend far down tho 



oesophagus, or into the larynx, trachea and 
bronchise, and upward into the nasal fossae. 
The membrane beneath and between the 
pellicles is in some cases of a bright red 
and in others purplish or livid. The exu- 
dations vary in density, from that of coag- 
ulable lymph, to that of soft pultaceous 
matter." 

" The local sensations are similar to those 
of angina diffusa, with the addition of that 
produced by irritation and obstruction of 
the air passages, when the disease has ex- 
tended in that direction. It is common 
also for the sub-maxillary and cervical 
glands to become inflamed and tumefied. 

" The general symptoms are those of fever, 
and vary with the type of the latter and 
the degree of the inflammation. Where the 
patches are but few and circumscribed, the 
disease is often called ulcerated sore 
throat, such as may be seen in scarla- 
tina anginosa, but there are no ulcers in 
these cases, for on removing the pellicles or 
sloughs, as they are called, we find the 
membrane beneath quite free from any 
other disorganization than the loss of its epi- 
thelium. In the worst cases, the pellicles are 
discolored by the admixture of bloody exu- 
dation and vitiated secretions of the throat, 
so as to create an impression that the parts 
are in a state of sphacelus. 

"These casts correspond to the angina 
maligfia of others; but we have the united 
testimony of Bretonneau, Guersent, and 
Deslandes, formed on extensive micro- 
scopic observations, that there are no true 
eschars in these cases. The idea of gan- 
grene existing has been further kept up by 
the discharge of serous and fetid matter 
from the nostrils, and by the putrid char- 
acter of the fever. Instances of this des- 
cription are very rarely met with, excepting 
when the disease prevails as an epidemic. 

"From the above, it appears that angina 
membranacea occurs in two forms. J In 
one the local affection bears the marks of 
active inflammation, in the bright hue of 
the mucous membrane, and in the white, 
circumscribed exudations, unmixed with 
blood or sanies. 



DIPHTHERIA AND SCARLET FEVER. 



403 



" The constitutional symptoms in this form 
arc likewise sthenic, the pulse being full and 
firm, the skin warm, and the nervous sys- 
tem — though disturbed — not exhibiting the 
prostration so common in typhoid forms. 
The other variety may well be called an- 
gin maligna. 

"Its approach is often insidious,being at- 
tended with little pain or disturbance in the 
throat till the false membrane is already 
extensively formed, then the dysphagia be- 
comes extreme ; liquids are forced back 
through the nostrils, and symptoms soon 
occur denoting that the air passages are ob- 
structed ; such as a croupy cough, hoarse- 
ness, and stridulous breathing. 

" The feeling of suffocation accompanying 
these symptoms, is in part owing to the 
swelling of the lymphatic glands. On in- 
spection of the throat, we see a thick pel- 
licle, sometimes dense, not unfrequently 
pultaceous, variously colored, according to 
the degree of its decomposition, or to the 
accompanying secretions, and either con- 
tinuous or interrupted by fissures which 
exhibit the livid hue of the membrane 
beneath. The pulse is extremely rapid 
and feeble, delirium sets in early, and is 
soon followed by coma ; and the collapsed 
face and sunken eyes indicate extreme ex- 
haustion. Death often takes place sudden- 
ly from the laryngeal complication. 

" Bretonneau was led by the results of his 
dissections, to attribute the death, in all the 
fatal cases, to the changes in the air pass- 
ages. 

"As might be expected, a priori, the vic- 
tims of malignant angina, are persons living 
in humid districts, where the disease is oc- 
casionally epidemic ; among the inhabitants 
of crowded buildings, and the poor ill-fed 
classes of the community. 

" Persons, however, not under these de- 
pressing agencies, may be attacked by a 
severe form of the disease. Children are 
?nore liable to it than adults. Whether it is 
propagated by contagion is not absolutely 
determined, but there are strong presump- 
tions in favor of this view. When the af- 
fection is epidemic, the difficulty of dis- 



tinguishing the operation of some generally 
diffused cause from that of contagion, 
meets us in this disease with the same force 
as in other epidemic maladies. The most 
unexceptionable instances of contagion are 
those in which the sporadic form has been 
transmitted from one person to another. 
Guersent relates the case of a nun who 
caught the disease from a little girl whom 
she had nursed in the Hopital des Enfans, 
and he remarks that practitioners are fre- 
quently attacked after inspecting the throats 
of their patients. That the inflammation 
of the mucous membrane takes place in 
angina membranacea cannot be denied, 
but why it should cause the secretion of 
coagulable lymph, rather than of serum and 
mucus, which are the ordinary products of 
mucous inflammation, cannot easily be ex- 
plained. It is probable, however, that the 
peculiarity does not depend upon the local 
action merely, but upon the state of the 
constitution previously modified by epidemic 
influence. 

"In this disease there is frequently ob- 
served an erythematous or papular eruption 
on different parts of the body, and there 
can be little difficulty in arriving at the 
conclusion that it is a variety of scarlatina 
maligna" 

Dr. Tweedie further says: "We are in- 
clined to affirm that scarlatina simplex, 
scarlatina anginosa and the scarlati?ia or 
angina maligna, and the sore throat, with- 
out efflorescence on the skin, are merely 
varieties of one and the same disease." 

REPORT OF CASES. 

The following communication contains a 
report of several well-marked cases of an- 
gina maligna which were attended and re- 
ported by Dr Effinger: 

Dear Doctor: At your request, I have 
kept a careful record of the following well- 
marked cases of angi?ia maligna, from 
which I have sent you, from time to time, 
as the disease progressed, samples of blood, 
urine, exudations and sloughs. 

Case I. — Amos Bear, a strong, healthy 
young man, aged seventeen, was taken 
down December 4th, 1862. 



404 



DIPHTHERIA AND SCARLET EEVER. 



Thursday morning, December 4th, he 
felt so badly that he remained in bed and 
ate no breakfast or dinner. Towards even- 
ing he vomited, felt pain in throat, neck 
swelling rapidly, externally. Sent for me 
about dark; could not see him that evening; 
prescribed a cathartic and foot bath, and 
flannel cloths wrung out of hot vinegar and 
sprinkled with salt, to be applied about the 
neck. 

Friday, 10 A. M., Dec. 5 th, made my 
first visit; found him in bed, face anxious 
and look depressed; pulse 92; not much 
fever or heat of skin; back and side of neck 
much swollen; more cedematous than gland- 
ular. 

On examination of throat, discovered a 
large diphtheritic patch, one inch in diam- 
eter and oval in shape, on left tonsil. It 
had a dark, ashy appearance, was of soft 
consistence and easily penetrated, with 
well-defined edges; breath offensive, with a 
sickly meatish smell. The right side of the 
throat was deeply infected, engorged to a 
purplish hue, with a slight bloody exuda- 
tion from a small surface posterior to the 
tonsil. Continued external applications, 
and left chlorate of potash to be taken in- 
ternally every four hours and used as a 
gargle. 

Saturday, 12 M., Dec. 6th. — Pulse 92. 
General symptoms same as yesterday; no 
change in slough on left side; some lumps 
of putrid matter, separated with difficulty by 
a spoon-handle; fetor of breath more de- 
cidedly putrid than before. On the right 
tonsil, a well-defined diphtheritic exudation 
had made its appearance, three-fourths of 
an inch in diameter, closely adherent, but 
the edges could be slightly raised. The 
purplish engorgement not quite so distinct 
as yesterday. Continued treatment, with 
addition of mur. tinct. iron, and a more 
liberal diet. 

Sunday, 1 P. M., Dec. 7th. — Patient not 
so well; had a bad night; forehead hot, 
pulse 92; more lassitude than before. Fetor 
of breath intolerable, decidedly putrid. 
Slough on left side about the same; dark 
fetid shreds removed, showing considerable 



depth of slough. On the right side, the 
diphtheritic patch was much increased in 
size, oblong in shape, extending below the 
tonsil as far as could be seen. It is much 
thicker than yesterday, of a whitish yellow 
color and more adherent. The mucous 
membrane on its edge still of a dark, livid 
color; obtained a sample of his morning 
urine, and the hawking expectoration pro- 
duced by my examination, which I sent you. 
Applied wash of nitric acid, diluted two- 
thirds, freely, to both sides; general treat- 
ment continued, with iron omitted. 

Monday, 4 P. M., Dec. 8th. — Had a very 
comfortable night; feels better; pulse &6; 
no heat of skin; fetor of breath not so of- 
fensive; slough on left side evidently ar- 
rested; dead lumps easily detached. On 
the right side, the tripe-looking membrane 
has extended over the dark, livid border of 
yesterday. 

It now has an oval shape, and is larger 
than the slough opposite; its lower edge 
well defined a short space below tonsil. 
Edges closely adherent; cannot yet be de- 
tached by gentle force. Took from arm 
\ x /z ounces of blood for examination, which 
I sent you, with some sloughs from fauces 
and a sample of his morning urine. Applied 
freely the nitric acid, and commenced the 
iron again. 

Tuesday noon, Dec. 9th. — Amos not so 
well to-day; pulse 100; forehead too warm; 
neck still much swollen in front, as well as 
on sides; pulse rapid, feeble, and not of 
much force; poison evidently telling on the 
general system; throat same as yesterday, 
except on the right side, where, under the 
diphtheritic exudation, there is apparently 
a large slough; tried to separate it, but the 
least touch made the exposed surface bleed, 
and I discontinued my efforts. After a 
slight laxative, bowels being constipated, 
ordered quinine and iron, with nourishing 
food. I used no topical applications, except 
chlorinated soda and potash. 

Wednesday, 12 M., Dec. 10. — Amos lias 
less fever; pulse 92 and feeble; face hag- 
gard, and I do not like the expression of 
his eyes; continued the quinine and mur. 



DIPHTHERIA AND SCARIET FEVER. 



405 



tinct. iron, with liberal diet. The slough 
on left side is clearing somewhat, but still 
looks badly. The left side is perfectly foul 
and ragged. I detached a portion that 
was loose, which I sent you in the bottle, I 
believe, on Saturday. I detached a few 
shreds from this side, and sent them to you 
between glass slides. You can readily dis- 
tinguish them by their dirty-white appear- 
ance and tripe - like consistence, being 
tougher than the porous soft lumps from 
the left side. In the bottle you will also 
find some soft matter that I scooped with a 
spoon-handle from immediately under the 
exudated membrane. 

Thursday, 3 P. M., Dec. nth. — Amos 
has had a bad night. The diphtheritic ex- 
udation has appeared on uvula and palatine 
arch, on the right side. They are much 
swollen, and render deglutition very diffi- 
cult. He drinks with great difficulty even 
water; most of it comes back through his 
nose. 

It is evidently spreading upward, and is 
in the nasal fossae. No difficulty yet in 
breathing. I obtained his morning urine 
and some expectoration, and matter from 
throat, which I sent you. I also sent you 
a large bottle of water from the Bear Spring. 
Pulse 96 and feeble. 

Friday noon, Dec. 12th. — Amos is worse, 
prostration more apparent ; difficulty of 
swallowing increased ; the respiration more 
labored, and I fear the diphtheritic exuda- 
tion has reached the bronchi ; pulse 100, 
and feeble. The diphtheritic membrane is 
covering the velum palati and the arches 
to-day, for the first time. 

I penciled the edge with nitrate of silver, 
hoping to arrest the spreading. Neck, back 
of ears, and half way down very much 
swollen, and just above the sternum very 
cedematous. 

Saturday 10 A. M., Dec. 13th. — The 
diphtheritic exudation has traveled beyond 
the penciled caustic mark. 

The specimen I send you to-day speaks 
for itself. You see the dark line ; all be- 
yond has spread since yesterday noon. 
This specimen was taken from the uvula. 



Amos is sinking ; respiration still more 
labored, and deglutition impossible. You 
can hear his laborious breathing all through 
the house. Under the separated exudation 
from the uvula, there is no slough, simply 
a raw bleeding surface. The swelling of 
the neck noticed yesterday has to-day al- 
most entirely disappeared 

Sunday 10 A. M., Dec. 14th. — Amos is 
still living, respiration becoming more and 
more difficult. Asphyxia is creeping on 
slowly but surely. Obtained a sample of 
morning urine which I sent you. 

Monday, Dec. 15th. — Amos died at 1 P.M. 
Death painful. Died of suffocation. Exu- 
dation extends into bronchi, and probably 
into pulmonary air cells. 

Case II. — Nancy Bear, sister of Amos, 
aged 21. For some months prior to her 
brother's illness, Nancy was absent from 
home, visiting relatives, some twenty 
miles distant. On Saturday, Dec. 13th, 
the family sent for her, and she came 
home on horseback, the evening of the 
same day. Though much fatigued, she 
hung over her gasping brother that 
whole night. She was constantly about 
him till he died, giving way very 
much to her feelings. She became com- 
pletely prostrated on Monday ; fainted at 
the church on Tuesday morning at the fu- 
neral, and had to be carried home. I was 
sent for Tuesday afternoon. 

Nancy is a heavy, thick-set girl of leuco- 
lymphatic temperament ; general health 
good. I saw her about dusk. Found her 
nervous and prostrated, but with no tangible 
disease, except a severe coryza affecting 
nasal cavities and frontal sinus. I advised 
salt water pediluvium, and a cathartic at 
bed time. 

Wednesday, Dec. 17th. — Was called 
again to see her. Complained of soreness 
about the neck and throat. Both nostrils 
were completely stuffed up with ropy mu- 
cus, and the throat so filled as to interfere 
with the examination of parts, but being re- 
moved, no sign was seen of diphtheritic 
exudation ; but the next day, Dec. 18, after 
a careful swabbing out of the throat, I de- 



406 



DIPHTHERIA AND SCARLET EEVER. 



tected a slight pearly exudation on the left 
tonsil. 

Friday, Dec. 19th. — The symptoms about 
the same as yesterday. 

Saturday, Dec. 20th. — Was much im- 
proved, the nasal catarrh being the promi- 
nent symptom, and the white adherent ex- 
udation not increasing. Nancy was sitting 
up, was cheerful, and said she was much 
better. 

Her beau called to see her as usual, Sat- 
urday night, and she imprudently remained 
up with him most of the night. 

Sunday, Dec. 21st. — Was sent for. Found 
her much worse, the tonsils and velum were 
swollen and red, swallowing difficult, the 
voice hoarse and the breathing labored and 
painful. Auscultation of left lung gave the 
sibillant rhonchus. Clearly was it evident 
that the catarrh of the nasal passages had 
crept down into the trachea and lungs, and 
that the whole mucous membrane of the air 
passages was now involved. Still there 
was no increase of exudation in the throat 
beyond the slight patch on the left tonsil. 

Monday, Dec. 22nd. — Had a restless night. 
On raising the velum, evidence of diphthe- 
ritic patches were seen on the fauces, high 
up. The nostrils were filled with mem- 
brane, but not easily detached. 

Tuesday, Dec. 23rd. — With my polypus 
forceps, I detached specimens, from both 
nostrils, one-eighth of an inch thick, which 
I sent you. In the throat it was only too 
apparent, both in fauces and on tonsils ; in 
appearance, white, glossy, thin and closely 
adherent, but in patches. It never became 
continuous though she lived for a week 
longer. 

Wednesday. — Disease gradually progress- 
ing. 

Thursday, Dec. 25th. — Obtained some 
blood from Nancy's arm ; the blood flowed 
directly into the smaller bottle. The blood, 
in larger bottle flowed into a saucer, and 
after standing for a short time, was poured 
into the bottle. Obtained also some mem- 
brane from throat and nose,with some freshly 
expectorated mucus, which was sent to you. 



Friday, Dec. 26th. — Nancy is about the 
same as yesterday. 

Saturday, Dec. 27th. — Nancy appears 
to be improving and there is some hope 
that she may recover. 

Sunday, Dec. 28th. — Worse than yester- 
day ; very weak ; breathing labored, and 
pulse rapid and feeble. The exudations 
have extended into the tracheal and bron- 
chial passages. From this time, the breath- 
ing grew more and more labored, until she 
died asphyxiated, like her brother Amos, 
on the night of January 1st, 1863. 

Case III. — Jesse Bear, brother of 
Nancy, a fine healthy boy, aged 8 years 
was taken down Dec. 22nd, '62. 

Dec. 25th. — Jesse very sick, has a large 
diphtheritic exudation on each tonsil. 

Dec. 27th. — Large and extensive exuda- 
tions, but very little constitutional disturb- 
ance. Obtained his morning urine and 
some of his expectoration, which I sent 
you. Jesse continued to fail and the exu- 
dation to pass lower and lower into the 
trachea and bronchi, till, on January 6th, he 
expired as did his brother Amos. 

Case IV. — Peter Bear, brother of Jesse, 
a strong healthy boy of 12 years, was 
taken down with the disease, Dec. 25. 

Dec. 27. — Fever very high; exudation on 
right tonsil; vomited while I was penciling 
his throat; a sample of vomited matter I 
sent you; Peter's case was one of sim- 
ple angina membranacea and did not ter- 
minate fatally. There were three other 
cases in this family. Mrs. Bear, who had a 
slight attack; Susan, a young daughter, and 
a little grand-daughter, all of whom recov- 
ered. The only persons escaping were Mr. 
Bear, and his eldest son aged about 23. 

Yours, truly, 

M. Effinger. 
Dr. J. H. Salisbury. 

From Dr. Efnnger's report it will be seen 
that out of seven cases in the Bear family, 
three died and four recovered. In almost 
every instance, when malignant diphtheria 
{angina maligna) appeared in a family, it 
was equally, if not more fatal. In support 



DIPHTHERIA AND SCARLET REFER. 



407 



of this fact, we will mention briefly the fol- 
lowing instances: 

Mr. Bailor had six children, and one 
grandchild, all of whom had diphtheria. Four 
died, and three recovered. Of the four 
that died, three were female, and one male; 
they were respectively three weeks, seven, 
eleven and twenty years of • age. Of 
those that recovered, one was the married 
daughter who had but a mild attack of an- 
gina membranacea.The ages of the two others 
were respectively thirteen and fifteen years. 
Of the daughter aged eleven, who died, one 
leg became gangrenous to the knee several 
days before death. One foot of the boy 
aged 7 was very much swollen and also final- 
ly became gangrenous before death. 

Dr. Lewis attended this family. In the 
Sandris family the mother and all the chil- 
dren, six in number, had the disease. 
The mother and four of the children died, 
so that out of seven cases in this family, 
only two recovered. 

In Mr. Karn's family out of tour chil- 
dren that -had the disease three died. Their 
ages were respectively five, eleven and four- 
teen. A grown daughter, aged about twen- 
ty-one, and a nursing infant escaped with- 
out taking the disease. Dr. Lewis attended 
this family. In two of these cases, the feet 
and legs up to the knees became pulseless 
and cold twenty-four hours before death, 
and there was a disposition to gangrene. 

In the Brooks family, all of his children, 
three in number, had the disease, two re- 
covered and one died. In Warren Stripes' 
family, two grown daughters, the only chil- 
dren at home, had the disease. One recov- 
ered and one died. The first one taken 
down, four or five days previous to the at- 
tack, visited Mr. Bailor's family, and help- 
ed to "lay out" one of his children that 
had died of the disease. In Mr. Himes's 
family the mother and one child only had the 
disease. The former recovered and the 
latter died. 

In Mr. McCabe's family, all the children, 
six in number, had the disease, and all re- 
covered. 
From the foregoing statements! it will be 



seen that out of thirty-eight cases, there 
were eighteen deaths, and twenty recoveries 
Many of those that recovered, had merely 
the membranous type of the disease. This 
however will represent about a fair average 
proportion of the recoveries and deaths in 
those attacked with the disease, in the dis- 
trict previously mentioned, where malignant 
diphtheria prevailed. But few families in 
the district were exempt from the invasion, 
Since writing the foregoing, I have re- 
ceived the following letter from Dr. Lewis, 
in which are reported two interesting cases 
of angina maligna or gangrenosa. 

Lancaster, O., April 3d, 1863. 

Dr. Salisbury — Dear Sir: Your let- 
ter asking for a report of cases of diphtheria 
has been received. In referring to my notes 
of cases, I find that the epidemic which 
ravaged the south-west part of our coun- 
ty, made its advent on the 19th day of 
October, 1862. Two children were attack- 
ed simultaneously in the same family, one 
aged nine and the other eleven years, one 
male and the other female. These cases had 
progressed for four days, before I was 
called to see them. I cannot, from person- 
al observation, state the mode of the attac'.;, 
but at my first visit I found the eldest (a 
girl), with a quick, feeble pulse, cold ex- 
tremities; shrunken, pale and agonized 
countenance; unable to articulate; the par- 
otid and submaxillary glands enlarged; the 
tonsils enlarged; the uvula elongated and of 
an ashy appearance; the tonsils on the right 
side covered with a dark fetid slough, sur- 
rounding which was an areola of an ashy ap- 
pearance, beyond which the parts presented 
a dark cherry color, gradually disappearing. 
The case terminated fatally in about six 
hours after I saw her. 

The boy was in about the same condi- 
tion, but had a less aggravated form of the 
disease. He recovered. These two cases ap- 
peared to be the nucleus from which the dis- 
ease spread; mostly in a north-west direction, 
choosing the slopes of the hills and high table 
lands, rather than the summits and valleys. 

This disease in its progress presented 



408 



DIPHTHERIA AND SCARLET EEVER. 



two distinct forms; the first, and most usual, 
was what I have termed the malignant or 
typhoid. This form was ushered in by a 
low, quick pulse, a dry harsh condition of 
the skin, a feeling of fulness and uneasi- 
ness in the head (not amounting to head- 
ache) dry tongue, great thirst, the parotids 
and glands of the neck on about the second 
day becoming sore to the touch, the mus- 
cles of the neck at the same time becoming 
stiff, the tonsils, pharynx and uvula assum- 
ing a dark cherry or purple hue. In from 
six to twelve hours, a small yellowish-gray 
spot would make its appearance upon one 
cr both tonsils, about the size of a grain of 
wheat. This spot had the appearance of an 
erysipelatous blister, which would spread 
rapidly and burrow deeply, assuming a dark- 
brown or black hue, and forming in a few 
hours a fetid slough, which would, in the 
course of from thirty-six to forty-eight 
hours, begin to break down. > 

The condition of the skin remaining the 
same, the pulse becoming weaker,the strength 
failing rapidly, the pupil of the eye enlarged 
and vision partially lost, so that small objects 
could not be seen, and the disease often 
terminating fatally in from four to seven 
days. 

The other form I have taken the liberty 
of calling the inflammatory, to distinguish 
it from the typhoid form; its mode of attack 
being entirely different. Coming on with 
full, hard, bounding pulse, congested state 
of the capillaries, high fever, headache, 
nausea, sometimes vomiting, the tongue 
coated with dark-brown fur, the throat 
assuming a clean bright scarlet hue, the 
exudation making its appearance about the 
second day, and having the appearance of 
milk curd of a clear white cheesy character, 
easily broken down. This form was readily 
amenable to the ordinary treatment. No 
death occurred from such attacks, in my 
practice, which during the winter was ex 
tensive, fur I treated over one hundred 
cases from October, 1862, to February, 1863. 
A more detailed account of the following 
cases may be of interest : 

Case i. — Aged 11. Attacked Nov. 6th, 



and, from all I could learn, it appeared to 
be at first a mild form of the malignant type 
of the disease. I did not see the case till 
some four weeks after the attack. This 
with the succeeding case (2), was of much 
interest. The child was laboring under a 
low grade of fever, dry, husky skin, loss of 
appetite, partial vision, tenderness of abdo- 
men, periods of intense suffering occurring 
every two, three or four hours, which he 
attributed to a sore on his foot from which 
the skin had been rubbed by the shoe. Upon 
examining the sore, I found the extremity 
cold, the ulcer about the size of a dime, with 
a shrivelled bluish elevated border, the cen- 
tre of a dark fetid slough, without any ap- 
pearance of granulations, having much the 
appearance of a chancre. The ulcer con- 
tinued to increase in size, the foot assuming 
a mottled appearance. Soon the toes began 
to shrivel about the nails, dry gangrene 
made its appearance, soon invading the 
whole foot ; the brain became implicated, 
and the patient rapidly sank. 

Case 2. — Aged 13, sister of case 1 ; at- 
tacked about the same time, and, from what 
I could learn, in the same manner. I was 
unfortunate in not seeing this case until the 
lapse of about four weeks. When I did see 
the patient, found her in about the same 
condition as Case 1 at my first visit. After 
treating the case for some days, the ulcers 
in the throat gradually healed, but the pow- 
ers of life were far spent. Like her brother, 
she had upon her foot a sore caused by the 
chafing of the shoe. This sore was an ordi- 
nary one, showing considerable indisposition 
to heal, but an ordinary abrasion, till after 
the throat healed, when to my amazement a 
regular diphtheritic deposit made its ap- 
pearance upon the sore, which rapidly 
passed into an ulcer with the same appear- 
ance that was presented in Case 1 ; refus- 
ing to granulate, and absolutely maintain- 
ing that cold, flatly malignant appearance of 
the chancre. This ulcer spread by a grad- 
ual death of the tissue, not rapid but sure 
and persistent. In the course of ten or 
twelve days, gangrene showed itself upon 
the toes, gradually advancing until the tpei 



DIPHTHERIA AND SCARLET REFER. 



409 



were entirely involved. Mortification now 
made its appearance in the foot around the 
abrasion caused by the shoe, which spread 
slowly until it reached a point about three 
inches above the ankle joint, where a partial 
line of demarcation was formed, and gradu- 
ally became more distinct for four days, but 
finally claimed more, and gangrene slowly 
continued up the leg until the whole mem- 
ber was involved, and the little patient was 
relieved from her sufferings. 
Very respectfully, 

J. W. Lewis. 

The two cases reported by Dr. Lewis, 
where gangrene attacked the extremities 
several days previous to death, are highly 
interesting. It appears that these two cases 
had lingered under the influence of the dis- 
ease some four weeks previous to the first 
visit of the Doctor, and that gangrene did 
not set in till several days after. The 
diphtheritic exudation on the surface of 
the abrasion on the foot of each of these 
patients shows that the morbific cause had 
pervaded the entire system, and that it is 
capable of producing a gangrene in the ex- 
tremities, similar to that which it causes in 
the original region. 

MICROSCOPIC EXAMINATIONS OF EXPECTOR- 
ATIONS, EXUDATIONS AND SLOUGHS 
IN DIPHTHERIA. 

The exudations and sloughs herein exam- 
ined were taken from the throat and fauces 
of Amos Bear, December ioth, the sixth 
day of the disease, and sent to me on the 
same day by Dr. Effinger. The membranes 
had the usual appearance of diphtheritic ex- 
udations. With them was considerable 
expectoration or mucous secretion of the an- 
ginal region. £ 
The cells of this mucous secretion had a 
peculiar and interesting appearance. The 
minute cell contents appeared more distinct 
than in health, and in many instances were 
in active and independent motion, moving 
rapidly among each other and around the 
large central nuclei. By carefully watch- 
ing the mucous cells it was also discovered 
that they too exhibit independent vitality, 



and had a slow progressive movement most- 
ly in right lines, either singly or in whole 
columns or in masses. This motion was 
very slow, but by watching, in many in- 
stances, a single cell for hours together, its 
movements and general metamorphosis were 
fully and satisfactorily determined. The 
mucous cells of the spittle and expectora- 
tion, as is well known, are the products of 
the parent epithelial cells, lining the air pas- 
sages, and those forming the secreting and 
organizing surfaces of the salivary system. 
These cells, in a normal or healthy condi- 
tion, immediately after being formed, have 
the appearance as seen at a, s and t, Fig. 
i, PL I. 

In the diphtheritic exudations and ex- 
pectoration, these cells have taken on an 
increased tendency to be metamorphosed 
into filaments, each being provided with a 
minute hair-like appendage and possessing 
the power of independent motion. These 
diphtheritic mucous cells are seen at b, c and 
h, Fig. i. PI. I. Their minute cell con- 
tents could be readily seen moving inde- 
pendently about among each other and 
around the central nuclei. As the vitalized 
mucous cells (b and h) gradually progressed, 
it was found that the hair-like appendage 
gradually became larger and longer, till it 
could be seen to be a tube, into which a 
portion of the minute cell contents of the 
mucous cell passed, (c) This metamor- 
phosis or filament development from cells 
gradually progressed till, after many hours, 
the cell entirely disappeared, having been 
spun into a filament like that seen at f. 
Fig. i, PL I Sometimes from two to 
many cells would be seen united in a mon- 
iliform line, the cells of which would begin 
to separate, remaining connected by a fila- 
ment as seen at d, e and m, Fig. i, PI. I., 
and this separation would become greater 
and greater, until the entire string of cells 
would be metamorphosed into a long tubu- 
lar filament containing in it a portion of the 
minute cell contents of the mucous cells. 



410 



DIPHTHERIA AND SCARLET EEVER. 



The only portions not metamorphosed 
into filaments were the large central nuclei. 
This operation of cell metamorphosis was 
watched day after day for several weeks, till 
I became fully satisfied that this general ac- 
tive filamentous development of the mucous 
cells was abnormal, and that from it result- 
ed the membranous exudations of diph- 
theria. It was satisfactorily determined that 
the diphtheritic membranes are formed by 
the rapid metamorphosis of the mucous 
cells into filaments, which process begins 
in this disease befoie they are fairly liber- 
ated from the mucous follicles, and even 
from the parent epithelial tissue. 

As the filaments are developed they be- 
come interwoven and thus form a more or 
less thick and compact adherent membrane, 
according to the activity of the secretion 
and the cell metamorphosis. The external 
surfaces of the exuded membranes have the 
appearance seen at r and q, Fig. i, PI. I. 

The filaments are so transparent, and 
their plastic walls become so blended with 
each other, that it is with difficulty they are 
distinguished after the membrane is fully 
formed. In its early stages, however, it can 
be readily resolved into its ultimate fila- 
ments, u. Fig. i, PI. I, represents the 
two kinds of minute cells, highly magnified, 
that have independent motion in the mu- 
cous cells, b. c and i, Fig. i, PI. I. p rep- 
resents the minute cells, highly magnified, 
seen on the surface of the fragments of ex- 
udation q and r. g are masses of sporidia 
of the sphaerotheca pyra — the species that 
produces blight in the apple, pear and 
quince trees and decay in their fruit, h, i, 
k, m, n and o, Fig. i, PI. I, represent the 
mucous cells in the expectoration and exu- 
dations of Nancy Bear, in their various 
stages of metamorphosis. Many other 
cases have been examined, all of which go 
to confirm the views here advanced. 

SLOUGHS OF ANGINA MALIGNA. 

The sloughs from the throat of Amos 
Bear were subjected to a careful microscopic 
examination. The bodies represented under 
Fig. 2, PI. II, were in the sloughs. 

Examinations of like sloughs from Mr. 



Karn's son and several others, revealed the 
same bodies with the single exception of 
the genus anguillila seen at a, Plate VI., Fig. 
6, which was only found in the sloughs of 
Amos Bear, and which probably came from 
some vinegar gargle he may have used. The 
minute forms represented at a, Fig. 1 1, PI. II 
are peculiar active bodies, which are really 
the spores of embryonic filaments of minute 
species of algae or fungi. The parent gland 
cells of animals have the power of taking 
in and transmitting freely the spores of this 
vegetation. All organic bodies are filled 
with these spores, which seem to be quies- 
cent during the physiological states, but as 
soon as pathological conditions arise they 
develop and multiply with incredible 
rapidity. They become very abundant 
during the fermentation and incipient de- 
cay of all organic matter, and especially so 
in nitrogenized animal tissues. At b, c, d 
Fig. 2, PI. II, are represented the mature 
algoid filaments, which are found in multi- 
tudes running in all directions through the 
exudations and sloughs, e, f, g and h Fig. 2, 
PI. II, are cells that have the appearance of 
being the spores and sporangia of the mucor 
maligiians described further on; g and h 
are more highly magnified than e and f ; i 
appears to be an ascus highly transparent 
and colorless, k and p. sporidia of the 
apple blight fungus, (sphaerotheca pyra), m. 
n and o sporidia, single and in mass of the 
sphaerotheca pyra, vegetating with myce- 
lial filaments. These occur abundantly in 
the sloughs. They are present in large 
quantities in apple fruit this season and may 
be carried into the system through the 
apples eaten. This species of fungus ap- 
pears to be poisonous to some vegetable 
tissues, and the sporidia excite irritation of 
the fauces, trachea and bronchi when inhaled. 
Another species Spersica (erysiphe graminis) 
produces the disease known as the " curl 
and blister" in peach leaves, and which 
proves so deleterious and destructive to 
peach orchards. Its known deleterious 
effects upon vegetation, together with its 
tendency to irritate the pulmonary mem- 
branes when inhaled, renders it probable 



DIPHTHERIA AND SCARLET EEVER. 



411 



that it may have some influence in exciting 
disease in the human subject. At b and x, 
Fig. 6, PI. VI, are represented two species of 
fungous filaments. These are found in the 
expectoration of diphtheritic patients this 
season. That represented at x occurs in 
vast numbers in ripe persimmons this year, 
in central Ohio, q Fig. 6, PI. VI. represents a 
sample of numerous knots of mycelial fila- 
ments, that are highly transparent, scattered 
over the surface of the sloughs, and 
patches of exudation. 

u, v and w Fig. 2, PI. II, large mucous cells. 

Besides the bodies represented under Fig. 
2, PI. II, there were numerous highly trans- 
parent large and loosely formed filaments, 
single and in bundles, that had the appear- 
ance of the mycelium, ce.Fig.3, PI. Ill, of the 
mucor malignans. There were, however, 
no fertile threads. Strongly suspecting 
that these filaments were fungoid, after cut- 
ting off a portion of the slough for further 
microscopic examination, I placed the bal- 
ance in a tightly corked two-ounce wide- 
mouthed bottle, and set it aside in a room 
where there was no fire. The temperature 
in this room ranged from 60 to 65 ° F. In 
a few days after being set aside, a white 
mould or fertile thread began to appear on 
the surface of the slough. This mould 
gradually increased till on December 28th, it 
enveloped the entire surface with a mass of 
white fertile threads that resembled fine 
cotton. On examining this under the mi- 
croscope, I found the surface fertile threads 
to emanate from the same mycelium as was 
noticed running all through the slough and 
exudation on Dec. ioth, when freshly sep- 
arated. 

At that time, however, there were no 
signs of fertile threads, and the mycelium 
was very much more transparent and less 
firm than on Dec. 28th. On placing this 
mycelium and fertile threads under the 
microscope, a most beautiful fungus in full 
fruit was exhibited, samples of which are 
seen at a, b, c, d, e and u, Fig. 3; PI. III. d re- 
presents the threads of the mycelium pack- 
ed together and filled with minute cells 
and granules, and covered often as at e 



with minute cells. Mingled with the threads 
were numerous highly transparent spore-like 
bodies, that had no connection with them. 
This fungus appears to belong to the genus 
mucor. Not having met anywhere with a 
description of this species, I have named it 
the malignanS) as at this stage of the inves- 
tigation it seems to have something to do 
as the cause of malignant diphtheria, as will 
more fully appear further on. 

a represents a fertile filament bearing tnree 
grape-likeclusters of sporangia. These bodies 
resemble mucous cells, and appear like the 
cells of diphtheritic exudation and expector- 
ation. The mycelium and minute cells are 
matted together in the exudation and sloughs 
of diphtheria, and covered with clusters of 
large cells, somewhat as seen at u, Fig. 3, PI. 
III. Often however, the large cells are most- 
ly absent. 

b, Fig. 3, PL III, represents a iertile fila- 
ment, covered with fruit or sporangias in 
an early stage of developement. m repre- 
sents the minute cells highly magnified, 
that fill the large cells. 

g, n, s and t Fig.3 PI. Ill, represent numer- 
ous active bodies moving about among the 
filaments, and which are seen at a,Fig.2,Pl.II. 

v,Fig.3,Pl. Ill, represents the mature fruit 
after it has separated from the fertile 
threads. These cells are what I have found 
frequently in diphtheritic exudation. They 
so much resemble mucous cells that they 
would readily be mistaken for them. I 
had supposed them to be mucous cells until 
I obtained the mature plants producing 
fruit. 

The minute bodies at w, Fig. 3, PI. Ill, are 
what appear to be the spores of the mucor 
malignans. 

Diphtheria Produced oy Inhaling the Spores 
of the Mucor Malignans. — On the 28th of 
December, before opening the bottle con- 
taining the diphtheritic slough and exuda- 
tion, covered with white mould, I locked 
nvyself in my room and opened the windows 
to prevent exposing the rest of the family 
to the disease. All the food I took for the 
next three days was hastily passed to me by 
my wife through the door slightly opened. 



412 



DIPHTHERIA AND SCARLET FEVER. 



I was determined to make careful micro- 
scopic examinations and drawings of the 
fungus, with full description of all the cir- 
cumstances and conditions, no matter what 
might be the result to me. 

In removing the cork from tne bottle, the 
slight jar sent the light spores out of the 
mouth of the bottle,appearing like the spores 
flying from a compressed " puff ball." 
These I freely inhaled. 

In a few minutes I had the vegetation 
under the microscope, and was making my 
drawings of the plant which are represented 
in Plate III., Fig. 3. 

My throat and fauces began to get dry, 
hot and feverish almost immediately after 
inhaling the spores. In less than thirty 
minutes, the same symptoms excited in the 
throat and fauces had extended down the 
trachea and bronchi, and seemingly into the 
air cells. With the dry, congested, hot 
feeling, was a heavy, persistent, dull pain, 
as if the parts affected were partially hepa- 
tized and useless. There was a feeling of 
oppression about the whole chest, and the 
breathing unsatisfactory and labored. These 
feelings became more and more intensified, 
so that in a few hours I was almost inca- 
pacitated from going on with the micro- 
scopic work and drawings. The spores had 
passed so freely and deeply into the air pas- 
sages, and the oppression and irritation of 
the parts was so intensified, that I began to 
fear that I should not be able to pursue the 
investigation further, unless I could get re- 
lief. 

Believing the cause of my suffering to be 
the spores inhaled, I immediately began 
taking one grain of quinia sulph. every 
thirty minutes; and also to inhale and snuff 
an equal amount at the same time. In ad- 
dition to this, I gargled a strong solution of 
tine, ferri chloridi every time my throat 
became dry and sticky. In a short time 
the troublesome irritation in the throat, 
fauces and air passages began to be relieved, 
so that I was comparatively comfortable 



and able to go on with the microscopic work 
and drawings. 

I am fully satisfied from what occurred 
during the attack and from my subsequent 
experience with the disease, that I should 
probably not have recovered if I had not 
treated myself heroically, as I did; for the 
mucous membranes of the entire air pas- 
sages were inoculated with the cause of the 
most malignant type of diphtheria I have 
ever met with. 

The quinine, taken internally and inhaled 
every half hour, kept the system and sur- 
faces so saturated with it that the vegetation 

could make but little headway, and conse- 
quently the disease was comparatively 

light and soon overcome. The disease was 
accompanied by a ropy, adhesive exudation, 
which excited hawking and spitting fre- 
quently. The same state extended down 
the oesophagus, and into the stomach and 
intestines. 

Bowels (which were before regular and in 
fine, healthy condition) became constipated, 
and faeces hard and plastic. During the night 
there was considerable burning, heavy pain 
in the stomach and bowels, aggravated by 
lying on the abdomen, and eased by lying 
on the back. There was scarcely any ten- 
derness on pressure. Counter irritation 
produced no relief. 

On the following morning, the first mucus 
that was coughed up contained many of the 
bodies v and the spores w, Fig. 3, Plate III. 
Hawking to dislodge the adhesive mucus 
would excite hiccoughing, while but little 
matter would be raised. Coughing aggra- 
vated the pain. 

Dec. 30th and 31st. — All the symptoms 
were aggravated. On the 30th there was 
considerable fever, with a dry, hot, heavy, 
congested feeling of the whole mucous lining 
of the air passages and oesophagus, stomach 
and intestines. Urine became scanty and 
high-colored, and deposited a large sedi- 
ment. There was a dry, pricking, con- 
stricting feeling in the throat and fauces, 
with a sticking together of the part. The 
mucous secretions from the air passages 
and mouth were ropy and filamentous, and 



DIPHTHERIA AND SCARLET FEVER, 



413 



the mucous cells had the appearance seen 
at Fig. i, Plate I. 

There was also pain in the sides of the 
neck, in the thyroid cartilage, and in the 
parotid and sub-maxillary glands. During 
the night, slept well. 

Dec. 31st. The back part of the throat 
and fauces were covered with diphtheritic 
exudations. The mucous membrane of the 
air passages and digestive canal felt less 
congested and hot, and the secretions of 
the bronchi and fauces were less ropy, and 
had less tendency to pass into filamentous 
metamorphosis. Bowels less constipated. 
Urine still scanty and high colored, with a 
large sediment. 

1863. January 1st. — Still better. The ex- 
udation patches in the throat are disappear- 
ing, and the secretions of the air passages 
less ropy, and bowels quite regular, appe- 
tite good. Continue the quinine sulph. 
every half hour. 

January 4th. — Have been constantly im- 
proving since the first. The diphtheritic 
patches have entirely disappeared, and feel 
quite well except a heavy, aching pain in 
the laryngeal and pharyngeal region, with 
a slight difficulty in perfect articulation. 

This latter result is of frequent occur- 
rence after recovery from severe attacks. 
Often this partial paralysis of the anginal 
region lasts for some days after recovery 
from the disease. 

A good illustration of the contagiousness 
of the disease occurred in this instance. 
Notwithstanding the precautions taken, 
about eight days after the appearance of 
the first symptoms in my case, my wife was 
taken down with the disease. The only 
exposure she had was in passing the food 
to me through the slightly opened door, 
and this only for a moment, three times a 
day. Her attack was sudden and severe, 
and required energetic treatment to prevent 
the exudation from extending into the 
bronchi. Two days after her attack, her 
sister was taken down, and on the follow- 
ing day her brother. All recovered. 

Blood in Diphtheria. — The blood cor- 
puscles of malignant diphtheria are plastic 



and sticky, and have a peculiar tendency to 
adhere together, and to filamentous meta- 
morphosis, showing that the disease is not 
local but systemic, probably influencing 
and modifying the organizing functions of 
the parent cells of the lacteal and lymphatic 
systems and spleen — in short, the entire 
parent gland cell tissue. 

At Fig. 4, Plate IV., are seen the various 
abnormal conditions and bodies of the 
blood of angina maligna. At a and b are 
seen masses of cells, resembling diphtheritic 
anginal cells. They are, however, colorless 
corpuscles formed by the spleen and the 
lacteal and lymphatic glands, and contain 
the micrococcus spores of the diphtheritic 
fungus. 

This peculiar tendency to stick together 
and become aggregated in irregular masses 
is abnormal. 

At c c, Fig. 4, PI. IV, are thin, pliable 
sacks, constantly changing in shape, filled 
with minute, vitalized granules constantly in 
motion — protoplasmic. 

The sacks have an amceba-like motion, 
and communicate with the cavities of the 
cells b, and their contents are the minute 
cell contents of these cells, d represents 
these minute, independently moving gran- 
ules, more highly magnified, e a cell like 
those at i and b, Fig. 1, PI. I, having a 
hair-like appendage, it having taken on and 
commenced the process of filamentous met- 
amorphosis, f rhomboid epithelial cells, 
that are removed from their attachment and 
are floating in the blood, g a large cell 
passing into a filament. At h and k are 
represented algoid filaments that occur 
in little groups and skeins in the blood. 

Attached to the filaments k are many 
spores of the vegetation, m and n are 
masses of fibrin, through and in 
which are seen algoid filaments. i 
filaments resembling filamentous neu- 
rine. This kind of filament was frequently 
met with in the blood of Amos Bear. All 
these bodies occur abundantly in the blood, 
showing a formulative condition, and a dis- 
position in its cells to become metamor- 
phosed into filaments, and a tendency in 



414 



DIPHTHERIA AND SCARLET FEVER. 



these filaments to become aggregated in 
masses, forming clots. This explains why- 
there is a disposition to gangrene — from a 
kind of embolism in this malignant form of 
the disease, the algoid spores and filaments 
and spores, and the blood aggregating, 
forming masses, clots and emboli choking 
up the capillary vessels, so as to impede and 
in some cases entirely stop the circulation. 

Uri7ie in Diphtheria. — The lining mem- 
brane of the urinary organs also takes on 
diphtheritic functional derangements. In 
all cases of diphtheria, there is the same pe- 
culiar, flocculent, pinkish-white deposit, 
made up of minute granules of urates, like 
those at Fig. 5, PL IV. With these are many 
crystals of lithic acid, often very large, and 
having the appearance of those seen at a, 
b, c, d and f, Fig. 5, Plate IV. 

With these are frequently found cystine 
and the peculiar crystalline forms seen at e, 
d, and k, Fig. 5, Plate IV. 

Also epithelial cells and their products, 
undergoing the filamentous metamorphosis, 
with many algoid filaments. 

At i are represented crystals of the lith- 
ates of soda and ammonia, which frequently 
occur in diphtheritic urine, w and v 1 , Fig. 
7, Plate VI, represent peculiar mucous cells, 
ruptured by their minute cell contents es- 
caping, q and q 1 , Fig. 6, PI. V, spherical 
algoid cells uniting into moniliform fila- 
ments, g fungoid filaments, h and 1 the so 
called vibriones, which are united into em- 
bryonic algoid or fungoid filaments, m and 
m 1 , Fig. 6, Plate V, algoid or fungoid 
filaments already formed, in which no 
structure can be made out. t, u, v and w, 
Fig. 6, Plate V, various stages in the 
formation of algoid filaments, from the 
so-called vibrio, r and s are highly mag- 
nified. 

The bodies here represented in diphthe- 
ritic urine, under Fig. 5, PI. IV, are the result 
of careful microscopic examinations of the 
urine of twenty-three cases of well marked 
diphtheria. In one case that has come un- 
der my observation, through Dr. Effinger, 
the attending physician, the diphtheritic 
derangements were wholly confined to the 



bladder, it never producing any abnormal 
anginal conditions that were noticed by the 
patient. The patient was a married lady, 
this attack occurring while she was attend- 
ing on her husband, who lay sick with or- 
dinary diphtheria (angina membranacea). 

Treatment. — During the twenty years 
that have elapsed since making these inves- 
tigations and preparing this paper, I have 
treated several hundred cases of diphtheria 
with quinine sulphate and tinct. ferri chlor- 
idi, and I can only call to mind the loss of 
a single case, and that was a German boy, 
who would not take the medicine with any 
regularity. The quinia sulphate should be 
given by the mouth, in powder, every half 
hour, keeping the mouth, fauces and throat 
constantly covered and saturated with it — 
also snuff and inhale it at the same time, so 
as to keep the surfaces of the entire air pas- 
sages covered and saturated with it. 

In addition to this I have used the fol- 
lowing as a gargle: — 

Ijt Tinct. ferri chloridi 3 j 

Aqua 3 viij 

S. Gargle every hour. 

3 Carbolic acid (cryst. white) . . 3 j 

Salicylic Acid 3 ss 

Water 3 xii 

Pure glycerine 3 iv 

01. menth. pip gtt. xv 

S. Gargle every half hour before taking 
the quinia sulphate. 

The quinia sulphate is the remedy to be 
depended upon for checking the develop- 
ment of the case. 

There are many little things to be done 
to relieve and make more comfortable, such 
as hop poultices around the neck, so cov- 
ered in as to bring the steam from the hops 
up around the mouth, where it is inhaled. 
This often soothes and relieves the suffo- 
cating and croupy condition in children. 
The swallowing of small bits of ice often aids 
in loosening up the particles of exudation. 

Penciling the throat with alcohol also re- 
lieves the sufferings of the patient. 

If quinine cannot be obtained, any anti- 
septic remedy, or any medicine that will 



DIPHTHERIA AND SCARIET FEVER. 



415 



check or control the fermentation in a yeast- 
pot, or preserve meat from spoiling, will be 
useful in aiding the cure. Among these 
may be mentioned permanganate of potash, 
sulphites, all the mineral acids, salt, borax, 
benzoate of soda, potassium chlorate, sal- 
icylic'acid, carbolic acid, tinct. ferri chloridi, 
bromine, iodine, sulphur, &c , &c. * 

In certain conditions where the cough is 
croupy, and the membranes tough, and ex- 
pectoration adhesive and ropy, with a strong 
tendency for the disease to invade the tra- 
chea and bronchi, small doses of mercurial, 
often administered, check or control this 
dangerous tendency, so that the exudations 
become softer, membranes less adhesive, 
croupy cough ceases, and the patient 
begins to improve. 

Scarlatina, the Symptoms and Derange- 
ments of; Similar to those of Diphtheria. — 
The mucous cells of the anginal exudation 
of scarlatina, with the bodies found in the 
blood and urine, present marked similarities 
to those of diphtheria. 

In both diseases there is a strong tenden- 
cy for the cell products of parent epithelial 
cells to undergo filamentous metamor- 
phosis. 

The disease in both cases appears to em- 
anate from functional derangements in the 
organizing processes of the ultimate epithe- 
lial cells,and in part appears to result in a too 
rapid development of cells into filaments. 
The primary cause of both diseases, how- 
ever, must consist in some morbific agent, 
which operates upon these cells, poisoning 
the nutrient products which they originate, 
so that after a certain limited period, which 
is the period of incubation, the whole sys- 
tem begins to sympathize, and take on a 
series of abnormal actions, which are sim- 
ply systemic efforts to eliminate from the or- 
ganism the morbific poison, and which ac- 
tions constitute the symptoms or peculiar- 
ities of the disease. In this light the func- 
tional derangements in toe organic pro- 
cesses of epithelial cells, become simply a 
resultant action excited by the primary 
cause of the disease, and is one of the ef- 
forts of nature to eradicate morbific matter, 



by accelerating normal changes in organic 
processes. 

It should therefore be the constant care 
of the physician, not to run counter to na- 
ture in her efforts to cure the disease, but 
simply to so equalize, aid and modify her 
actions, as to alleviate suffering and guard 
against dangerous results. 

With these few preliminary remarks we 
proceed to the microscopic examination of 
the expectoration, exudation, blood, urine 
and the desquamated cuticle of scarlatina. 

Expectoratio7i and Exudation. — The pecu- 
liar abnormal and similar tendency to the 
filamentous development of the mucous 
cells of the expectorated and exuded pro- 
ducts of scarlatina and diphtheria, renders 
it evident that the anginal epithelial func- 
tional derangements in both diseases are re- 
markably similar. This similarity is found 
also to extend to the abnormal products of 
the blood and urine. This makes it conclu- 
sive that the same systemic, epithelial, func- 
tional derangements are common to both 
diseases. The results here obtained are 
confirmatory of Dr. Tweedie's supposition 
previously given. 

Fig. 7, Plate VI, represents the appearance 
of the mucous cells of the expectoration 
and exudation of scarlatina angina. By 
comparing the filamentous metamorphosis 
going on in these cells with that exhibited at 
Fig. i, PI. I, a remarkable similarity will be 
noticed. 

a. Fig. 7, PI. VI, represents the normal mu- 
cous cell immediately after being formed and 
before it takes on the active condition, or 
begins to manifest independent activity, b, 
c and h are mucous cells in scarlatina, in 
the active stage. , The most of the cells in 
this stage have a single fine caudal filament, 
resembling an extremely fine hair, tapering 
from the cell, and projecting from its pos- 
terior side, or from the side opposite to the 
direction in which it moves. Sometimes 
there are two or even three hair-like pro- 
cesses visible. The length of these hair 
like processes in the early stages is usually 
from two to three times the diameter of 
the cell. 



416 



DIPHTHERIA AND SCARLET FEVER. 



The motion of these cells is a very slow, 
uniform, progressive one, often so slow that 
even an experienced eye would fail to de- 
tect it, unless the attention was called par- 
ticularly to it, and the observations con- 
tinued on the same cell often for hours. 
By selecting,however, a single cell standing 
alone, and keeping the eye on it for some 
time, a perceptible movement is plainly 
manifest. 

In this stage of development or metamor- 
phosis, the cells are usually more or less 
elongated, though they often appear spher- 
ical. They have the power of changing 
their shape, sometimes appearing very 
much elongated,at other times slightly oval, 
and then spherical. 

All of these forms are noticed frequently 
within a brief space of time, in the same 
cell, while watching its motions. 

The elongation is always in the direction 
in which the cell moves. Before the cell 
becomes active the hair-like appendage 
(cilium) cannot be seen, and in many in- 
stances after motion has commenced these 
processes are so line that it is impossible to 
detect them,even by the best glasses. These 
cells contain a large central single or com- 
pound nucleus, around which are numerous 
minute spherical and oval granules or cells, 
many of which are in active motion. 

Those in active motion are probably 
sperm cells to these organisms, and the 
others germ cells. 

Following the stage of independent ac- 
tivity comes that of filamentous metamor- 
phosis. During this period the activity is 
slight,being confined to very slow, almost im- 
perceptible, forward motion,which takes place 
at short intervals, or appears to be some- 
what periodic. The hair-like projection 
becomes elongated and enlarged in calibre, 
and soon is seen to be a membranous tube. 
As tli is tube enlarges and elongates, the 
contents of the mucous cells (consisting of 
fluid and minute granules) pass into it, and 
the minute cells usually become arranged 
in a single moniliform row along its cavity, 
as seen at z Fig. I, Plate 1, d, e, 1, m and i, Fig. 
7, Plate VI. As the contents of the mucous 



cell pass into the tubular filament, it (the 
cell) grows smaller, and smaller till finally it 
entirely disappears, leaving simply the re- 
sultant filament.* 

Often two or more cells are united by 
one or more tubular filaments, i, m, Fig. 7, 
PL VI, z, Fig. 1, PL I. 

Sometimes two or more filaments proceed 
from the same cell, as seen at 1, Fig. 7, 
PL VI. The number of filaments is 
determined by the number of hair-like 
processes, and these are increased as 
the tendency to filamentous metamor- 
phosis is increased beyond the normal 
standard. At m two mucous cells have 
entirely emptied their minute cell contents 
into the connecting filaments. After the 
cells have disappeared, we have simple fila- 
ments, as seen at p and q, Fig. 7, Plate VI. 
Often the mucous cells arrange themselves 
in moniliform rows, as at n and o, Fig. 7, 
Plate VI. 

r are the minute cells and moniliform 
short filaments that make up the contents 
of the mucous cells. These are highly 
magnified. At the extremity of the forming 
filaments at g, Fig. 7, Plate VI, short, active, 
moniliform lines of minute cells and single 
cells are escaping. This has only been no- 
ticed in a few instances. 

u spores of the saccharomycetes cerevis- 
ise, which occur through the mucus sin- 
gly and in short, branching, moniliform 
rows. 

s and t highly refractive, oblate spheroid- 
al cells of a pearly appearance, containing 
bodies resembling spores, t is an edge 
view and s a side view. In the right hand 



* Here is described briefly an interesting organic 
process, one from which, when physiologically, or 
slowly and healthfully performed, emanate all the fil- 
aments of the muscular, fibrous and nerve tissues of 
the animal body, but which, when the metamorphosis 
is too hasty or rapid, becomes an abnormal action, 
resulting in a preponderance of solids, and, in con- 
sequence, congestions and exudations, the damming 
up of the capillary blood streams, checking and 
even stopping circulation locally, which may pro- 
duce the pathological states of inflammation and gan- 
grene. This subject will be more fully treated in 
another paper. 



DIPHTHERIA AND SCARLET FEVER. 



417 



cell at s are short filaments with the spores. 
The spores are of a reddish transparent 
orange color. 

Many of these cells are entirely empty. 
When mature they fracture from the cir- 
cumference towards the center at numerous 
points, allowing the spore contents to es- 
cape. They are quite numerous in the ex- 
udations, and are the same as b and c, Fig. 
8, Plate VII, in the urine. 

The expectoration and exudation in scar- 
latina contain numerous confervoid fila- 
ments, like those at h, f, Fig. 6, Plate V. 
e, n, i, Fig. 8, Plate VII., of the urine of 
the same disease. 

Blood of Scarlatina. — The appearance of 
the abnormal bodies in the blood of scarla- 
tina anginosa is so nearly identical with 
those seen under diphtheria, Fig. 4, Plate 
IV., that they will not require repetition 
here. 

Desquamated Cuticle of Scarlatina. — 
Dec. 19th. Placed about four grains of des- 
quamated cuticle from a scarlatina patient 
in a watch glass, with a little pure water, 
tightly covered and set aside at a tempera- 
ture of 65 ° Fahr. The dry cuticle was made 
ud of flat, scale-like epithelial cells, each 
containing a large central nucleus, sur- 
rounded by minute cells or granules. 

Twenty-four hours after the large central 
nuclei, s and s 1 , Fig. 9, Plate VII, of the 
epithelial cells n and q had taken an inde- 
pendent motion, and were moving about in 
the epithelial cells and escaping. 

After having escaped from the epithelial 
cells, the minute, hair-like appendages could 
be quite distinctly seen, as at a and b, 
Fig. 9, Plate VII. 

The movements were very much more 
active than I had previously noticed in the 
epithelial cell products of mucous surfaces. 
c represents the cells a and b after the hair- 
like processes have begun to enlarge into a 
tubular filament. 

d represents the spores of a minute algoid 
vegetation, that have escaped from the flat- 
tened epithelial cells. These spores move 
independently in all directions. 



e, f and k represent these spores united 
into moniliform filaments. 

m represents a blunt, tubular filament 
(algoid) with cells united in twos. 

g and h represent short, algoid filaments 
with cells united in twos and threes, and 
the lines of demarcation between the indi- 
vidual cells obliterated. 

r represents a long, algoid or fungoid fil- 
ament, with no appearance of cross lines or 
cells. The inside cells have united into a 
uniform inside tube. 

All of these filaments have the power of 
independent motion. 

The motions are slow, and consist of the 
waving or vibrating of their extremities — 
leptothrix ? 1 is a diatom from the water 
drank, u probably the urate of soda, x 
crystal, probably phosphate of lime. 

Urine of Scarlet Fever. — Fig. 8, Plate 
VII, represents the various abnormal bodies 
found in the urine of scarlatina, when the 
disease is at its height, a, b and e rep- 
resent a peculiar kind of flattened, oblate 
spheroidal cells, containing orange-colored 
sporoid bodies, a and b represent side 
views, and an edge view. They belong to 
the same class of bodies as s and t, v and 
w, Fig. 7, Plate VI. They occur frequently 
in the urine. 

d represents cells from the parent epithe- 
lial cells of the bladder. They are single, 
and also aggregated in masses, and many of 
them manifest a disposition to filamentous 
metamorphosis, e, Fig. 8, Plate V., and f 
and g, Fig. 6, Plate V., algoid filaments, 
made up of an outside tube enclosing a 
moniliform line of minute spheroidal or oval 
cells, bearing a close resemblance to ana- 
baina mollis. 

h r, Fig. 6, Plate V., represent a species 
of leptothrix. Attached to the filament h 
are a number of short ones, belonging to 
the genus anabaina. These short monili- 
form filaments are the prevailing ones in 
scarlatina urine, a single drop often con* 
taining many hundred, i, k and 1, Fig. 8, 
Plate VII., a species of hypheothrix which 
is quite frequently met with. o large 



3 



418 



DIPHTHERIA AND SCARLET FEVER. 



rhomboid crystals of lithic acid. These are 
quite abundant. 

w, Fig. i, Plate I., a large, partially 
collapsed, membranous sack, resembling 
those found in the tomato or apple, and is 
probably accidentally present. Fig. 8, Plate 
VII., r r r crystals of creatine. The crys- 
talline forms s, t and u are also sometimes 
met with. 

Some General Remarks connected with the 
Pathology of Fever 's, and the Tissues upon 
which Fever Poisons Primarily Act. — The 
first layer of cell organisms, through which 
food, medicinal agents and poisons have to 
pass in entering the animal body, is the 
epithelial. 

It is very evident that medicinal agents 
and poisons must act upon these cells, mod- 
ifying their organizing and nutritive func- 
tions, and the derangement produced must 
first exist in these cells, and secondarily the 
more highly animalized elements and tissues 
beyond become affected, through the poi- 
soned and medicated products furnished 
them by the epithelial tissue. 

There is hence evidence for believing 
that all febrile diseases, eruptive and other- 
wise, are intimately connected with func- 
tional and structural derangements of the 
cells of epithelial tissue. So intimate is the 
relation that these functional and struct- 
ural derangements appear to constitute the 
disease. The different functional and 
structural disturbances of the various por- 
tions of the epithelial structure would seem 
to give rise to the various types of fevers. 
The primary causes of these functional and 
structural derangements in most fevers are 
varied, numerous and obscure, while in 
others which are contagious they are more 
defined, each being excited only by a par- 
ticular, specific cause. 

Before entering upon a few general re- 
marks on the aetiology, &c, of fevers, indi- 
cated by microscopic investigations of the 
epithelial system in pyrexial states, I will 
briefly refer to some generally received 
views on these diseases. 

In primary fevers there is a general py- 
rexial state, without any evident patholog- 



ical lesion, there being, to the unaided eye, 
no observable localized disease. 

As all organs and tissues appear to par- 
ticipate in the febrile action, when it is once 
established, its seat appears, and is supposed 
to be, no more in one tissue than in another. 
It has however been noticed that the first 
symptoms of the manifest invasion present 
themselves through the nervous system. 

It has therefore been supposed probable 
that the " fever poison " first invades the 
animal system through the channel of the 
nerves. These nerve symptoms, however, 
will be shown further on to be probably 
but secondary results in the invasion. 

Cullen's definition of fever, modified by 
Christison, is as follows : " After a prelim- 
inary stage of languor, weakness and defec- 
tive appetite, acceleration of the pulse, in- 
creased heat, great debility of the limbs and 
disturbance of most of the functions with- 
out primary local disease." 

The great French anatomic schools, com- 
posed of able investigators, advanced a 
theory, which was generally entertained 
throughout Europe. 

This theory regarded fever as the " con- 
stitutional result, and its symptoms as the 
general expression throughout the system, 
of the effects of a localized process of dis- 
ease, having for its constant seat a part of 
the intestinal canal. 

In fevers there is an increase of tempera- 
ture above the natural standard of about 
4° Fahr. ; even during the algid stage of the 
disease, the elevation of temperature is 
present. 

This has been noticed to be a constant 
morbid condition of fevers. It is now gen- 
erally admitted that the chief source of the 
increased temperature in fevers, arises from 
increased activity of the causes which oper- 
ate in the production of the healthy tem- 
perature. 

The source of healthy animal heat is 
held to be developed by the nutrient 
changes perpetually going on in the tis- 
sues. 

An able enquirer — Virchovv — assumes 
that the nutrient metamorphosis of the 



'DIPHTHERIA AND SCARLET FEVER. 



419 



tissues is increased in fever, and as a natural 
and necessary consequence, this gives rise 
to increase of temperature. This nutrient 
metamorphosis consists of those organizing 
changes going on both in nutrient materials 
supplied to the system, and those interstitial 
changes by which the constituents of the 
body themselves are metamorphosed and 
removed. Virchow supposed that this in- 
creased metamorphosis was the consequence 
of some internal, excitant cause, the real 
nature of which is unknown. 

Lyon, in his work on fevers, p. 33, says : 
" Some facts determined by recent investi- 
gations and experiments would appear to 
show that the first steps in the establish- 
ment of febrile conditions are not to be 
sought for in the blood itself, or in any part 
of the circulating apparatus, but to indicate 
certain deranged conditions of the nervous 
system as more likely to furnish us with an 
explanation at once natural and proper on 
this point." Virchow believed that the ele- 
vation of animal temperature in fevers arose 
from a kind of paralytic condition of the 
nervous system. This is supposed to have 
been well established by numerous experi- 
ments. Becquerel, Brescher and Helm- 
boltz,in experiments on that kind of nervous 
irritation which excites muscular contrac- 
tion, found that it increased animal tem- 
perature. In opposition to this, Bernard 
has proved that section of the sympathetic 
nerve in the neck is followed by rapid in- 
crease of temperature in the corresponding 
half of the head. Brown Sequard's experi- 
ments are to the same effect. Weber has 
shown that the heart's action is arrested by 
the irritation of the vagi nerves. It has 
long been known that section of these 
nerves causes acceleration of the pulse. 

Ludwig and Hoffa have shown that in 
moderate irritation of the vagi, the lateral 
pressure of blood in the arteries is lessened : 
while Volkman andTowelin have determined 
that it increased after section of the nerves. 
Fraube has found that digitalis acts as an 
irritating stimulant upon the regulating 
nerves of the heart, and that a diminished 
temperature is produced by it, which he at- 



tributes to the diminished velocity of the 
I blood stream. 

From these experiments it has been in- 
ferred by authors " that the causes that reg- 
ulate the velocity, tension and other physical 
conditions of the blood stream and the 
vessels which carry it, seem unquestionably 
to reside in the nervous system, which ex- 
ercises a sort of regulator or moderator 
function over the circulation, and through 
the circulation over the animal tempera- 
ture." 

Cullen held that " the first link in the chain 
of fever actions, was a depressed brain and 
nervous system." The spasm (or tonic 
contraction) of the capillaries, he considered 
as resulting from the depression of the 
brain and nervous centers, and that the re- 
action of the circulation was an effort to 
overcome this state of spasm of the extreme 
vessels. After the tissues have become 
once deranged by being nourished with ab- 
normal food, organized by epithelial cells 
deranged in their functions, we might well 
expect to find them in a diseased, irritated 
condition, which would manifest itself by a 
train of abnormal symptoms, which would 
continue until the exciting cause was re- 
moved. 

With regard to the elevation of animal 
heat, we would state in this connection 
some few facts which go to show that ani- 
mal heat may to a considerable extent be 
developed by the organizing processes of 
epithelial cells. After animal life has 
ceased, we have known the temperature of 
the body of a horse twelve hours after 
death (temperature of atmosphere 4o°Fah.) 
to stand at 160 Fah. This high tempera- 
ture arose mostly from the rapid organic 
changes going on in epithelial tissue, and 
from interstitial tissue dissolution. We have 
known the body of a dog, poisoned with 
veratrine, twelve hours after death to stand 
at 90° Fah. In the development of yeast 
cells in fermentation, the temperature of the 
fermenting mass often rises (where large 
masses of matter are fermenting), to from 
120 to 150? Fah. 

In the decay of nitrogenized tissues the 



420 



JDIPHTUER1A AND SCARLET FEVER. 



temperature sometimes rises even above 
150 Fah. 

In the rapid interstitial changes going on 
in fevers, we might well expect to find an 
elevated temperature of the animal 
body. 

After the phenomena noticed in the mi- 
croscopic examinations of the epithelial cells 
in various parts of the epithelial structure, 
in health, during the period of febrile incu- 
bation, and after the manifest invasion of 
the disease, there appears to be evidence 
for believing that the nervous system is not 
the department of the organism first en- 
croached upon, or the avenue through 
Which the exciting cause of fever first pass- 
es, in invading the animal system. 

There is a cell structure making up a 
considerable portion of the organism, which 
possesses a life independent of the animal 
body, the cells of which vegetate and de- 
velop after animal vitality ceases, as has 
been fully shown in the preceding pages. 

This tissue is composed of cells, the func- 
tion of which is to assimilate and organize 
the nutrient matters of the food into the va- 
rious products which are designed to be ap- 
propriated in building up and nourishing the 
various tissues of the animal body. It is 
known by the name of epithelial tissue, and 
makes up the organizing portion of all 
glandular masses and surfaces. The cells 
of this tissue are extra-vascular, and so far 
as known, not supplied with nerves. All 
the external surfaces of, and avenues of ap- 
proach to, the more highly animalizcd parts 
of the system are covered and guarded in 
all and every part by these epithelial cells. 
Nothing can enter the system without first 
passing through the cells of this assimilat- 
ing and organizing epithelial envelope. This 
epithelial envelope is the ultimate basis of 
the entire organic structure. Its individ- 
ual cells are the avenues and apparatus 
through which all the nutrient materials of 
the food have to pass, and be assimilat- 
ed and organized, ere they are fitted to 
nourish and sustain the various tissues. 

The tissues themselves, outside of epithe- 
lial or glandular cells, have no power within 



themselves of organizing matter from food 
for their support. The epithelial cells are 
the avenues through which alimentary, med- 
icinal and morbific agents reach the syste- 
mic tissues, and are the ultimate bases of 
many important physiological and patholog- 
ical processes. 

All febrile excitants must consequently 
act primarily upon the ceils of this tissue, 
deranging their organizing functions so as to 
impart abnormal properties to the matters 
organized. 

The period from the commencement of 
the action of the deranging influences upon 
these cells to the time when the abnormal 
organized products begin to produce per- 
ceptible derangements in the nerve and 
other tissues which these organized matters 
nourish, is the period of incubation. Of 
the different types of morbific agents which 
produce the different types of disease, each 
acts in its own peculiar way upon these cells 
of extravascular life, producing in them 
specific changes in their organizing func- 
tions, which in each case results in a partic- 
ular type of disease. 

This matter will be more fully set forth 
in a paper in progress on the " Ultimate 
structure and functions of epithelial (gland- 
ular) tissue, and how influenced in function 
by morbific agents." 

It is through the cells of this tissue that 
most of our medicinal agents and poi- 
sons produce their beneficial or baneful re* 
suits. 

The study of the specific action of the 
various agents of the materia medica, &c, 
upon the gland cells, opens up a new and 
rich field for careful investigation, which 
will yet result in the discovery of ultimate 
organic actions and cardinal truths that will 
tend to reduce the healing art more to an 
exact science, and establish ( unvarying 
guides in many instances foi the practition- 
er. It is in studying the functions of this 
primordial structure in health and disease, 
and under the influence of medicinal agents, 
that we may expect to find much that is 
new and true respecting those obscure ulti- 
mate physiological and pathological changes 



DIPHTHERIA AND SCARLET EEVER. 



421 



and medicinal effects which lie at the very 
foundation of medical science, and which 
are so important to understand in order to 
free the practice of medicine from an empir- 
icism which has ever clung to it in defiance 
of past research. 

In fevers the organizing cells (epithelial) 
become dry, parched, and are so poisoned 
by morbific agents that their normal func- 
tions of organizing cells are much deranged, 
and to a great extent cease. 

Nutrient materials introduced into the 
stomach not being, save to a limited extent, 
assimilated and organized, act as foreign 
bodies, producing irritation of the intes- 
tinal canal and system generally. On the 
other hand interstitial death and decay be- 
come rapid, producing debility, emaciation, 
&c. This state of things necessarily results 
in the long train of symptoms attendant 
upon fevers. 

The rapid interstitial changes are efforts 
on the part of nature to purge the system 
of morbific materials which have already 
been organized and become incorporated in 
the tissues during the period of incubation. 
This morbific matter must be disposed of 
or eliminated before recovery can take 
place. 

The symptoms in any given case of fever 
are but the expressions of the extent to 
which the morbific poisoning has invaded 
the tissues, and of the efforts on the part of 
nature to rid the system of the poisoned 
epithelial products already appropriated, 
and the tendency to check the further or- 
ganization of products for nutrient purposes, 
until the system becomes purged of the 
fever poison. This explains the reason why 
it is so useless to attempt to " break up" well 
established fevers, except by removing or 
rendering inert the morbific cause. In pure 
fevers there are no perceptible organic le- 
sions. The disease is one of function in- 
stead of structure. The primary seat of 
the derangement is in the ultimate epithelial 
cells, the very basement structure of the 
organism. In eruptive fevers the cutaneous 
surface becomes involved, and there is also 
a tendency for the mucous and serous sur- 



faces to take on like pathological condi- 
tions. These fevers are distinguished from 
each other by the character of the surface 
lesions. In scarlatina and measles there is 
a peculiar tendency for the mucous mem- 
branes to become involved. The former is 
commonly attended with a peculiar and 
characteristic form of sore throat (diphthe- 
ritic), while the latter is usually accompanied 
by a watery exudation from the eyes and 
nose (coryza;, and a bronchial affection 
varying in extent and importance. 

In s?nall-j)ox there is a tendency to lesion 
of the serous surfaces (the pleura especially) 
and occasionally the mucous coats of the 
intestines arc involved (pustules on the mu- 
cous intestinal surfaces). 

In eruptive fevers and typhus, one at- 
tack gives a peculiar protective immunity 
against its recurrence in the same individual. 
The cause of this protective immunity may 
possibly be arrived at by carefully studying 
the changes impressed upon the ultimate 
epithelial cells by the specific causes of 
these diseases.* 

The spores of many algae and fungi and 
perhaps other cryptogams produce a febrile 
condition of the mucous lining of the air 
passages when inhaled. This febrile con- 
dition is local, and confined to the delicate 
parent epithelial cell surfaces with which 
the spores come in immediate contact. It 
often lasts from one to several hours after 
removal from exposure to the morbific cause. 
In walking over, disturbing, or pitching old, 
mouldy straw or hay, the throat, mouth and 
fauces become dry, hot and parched, and 
there is a constant desire to swallow, hawk 
and spit, with an almost entire suppression 
of the normal secretions of these surfaces. 

Very soon this dry, congested sensation 
extends into and throughout the air passages 
of the lungs, and is there accompanied by a 
heavy, congested feeling. 



* The length of time that this impress of immunity 
lasts in any given case is determined by the length 
of the life and existence of the epithelial cells re- 
ceiving the impress. Our epithelial cell envelope is 

constantly dying, disintegrating and disappearing 
and new cells are formed to take their place, so that 
the integrity of the envelope is constantly preserved. 



122 



DIPHTHERIA AND SCARLET FEVER. 



In walking over " peaty ague bogs," 
where the surface is broken, exposing the 
fresh soil covered with ague vegetation, 
during the months of July, August and 
September, or in passing through the heavy 
night air and vapors in malarial districts, 
the same or similar febrile sensations to 
those from mouldy straw and hay are ex- 
perienced.* 

These sensations often last for hours, 
and sometimes during an entire day, after 
removal from the morbific cause. On ex- 
amining the expectorated mucus, it is found 
filled with fungoid and algoid spores, and 
fragments of fungoid filaments. We have 
them here an exciting cause of local febrile 
excitement^ which any one may be fully sat- 
isfied of by exposing himself to the con- 
dition just described. That the morbific 
poison in these cases is cryptogamic, there 
is no possible doubt, as in hundreds of in- 
stances in our observations, where > this 
febrile condition of the air passages has 
been excited, the expectorated mucus has 
been found to contain uniformly fungoid 
and algoid bodies in great numbers : and 
further, these bodies were the only foreign 
substances in the mucus that was constant- 
ly present in such cases. 

Vllie atmosphere in certain localities, 
especially the heavy, damp, night atmos- 
phere, is often found loaded, during the 
season of active cryptogamic development, 
with the invisible spores of numerous mi- 
croscopic cryptogams, that multiply and 
develop with great prolificness, some upon 
living, some upon diseased, and others upon 
dead and decaying organic tissues. 

This established, we may go one step 
further and reasonably conclude that bodies 
which are capable of exciting local fever i?i 
the epithelial surfaces with which they come 
in contact, by a few minutes exposure to them, 
may, by frequent ana 7 long exposure of the 
system to the same cause, become so diffused 

* That this local febrile excitement acts primarily 
upon the epithelial cells is evident from the fact 
that the first abnormal indication noticed is the sup- 
pression of the epithelial cell secretion; the throat, 
fauces, bronchi and pulmonary membranes becom- 
ing dry, parched, &c. 



throughout the organism by being inhaled and 
taken into it with the food and drink, as to 
communicate their mo?'bific properties to the 
entire epithelial surfaces of the intestinal 
canal, and the lacteal, lymphatic, gla?idular 
and vascular epithelial surfaces, and so de- 
range the functions of the organizing cells as 
to render the products organized by them, for 
the nourishment of the nervous and all ether 
tissues of the body, poisonous. As soon as 
these poisoned nutrient products become appro- 
priated by the tissues, to a certain extent, the 
system gives way to those powerful efforts of 
nature, which are designed, ?wt only to pre- 
vent as far as possible the further introduc- 
tion of the fever poison, but by rapid inter- 
stitial changes eliminate from the organism 
the poisoned organized matters that have 
already been appropriated by the tissues during 
the period of incubation. 

The sum of these manifestations of nature 
constitutes the disease known as fever. w 

These remarks apply to all fevers, and 
especially to those which are not regarded 
as contagious. In those that are contagious 
there are generally surface lesions in the 
shape of eruptions. In this class, called 
eruptive, the morbific cause is no doubt 
of a similar character to that of other fevers, 
but seems to possess in addition the pecu- 
liar property of those organisms known as 
" yeast plants," capable of multiplying 
almost infinitely in the animal system from 
a small beginning. The animal system to 
this vegetation seems to be a prolific u hot 
bed," in which they develop and multiply 
and extend without limit. They also pos- 
sess the peculiar property of impressing upon 
the epithelial cell system the power of resisting 
to a remarkable extent subsequent invasions of 
the same disease. 

It has been, however, observed, that as 
the period lengthens from the time of the 
first invasion of the disease to subsequent 
exposures, the tendency becomes greater 
and greater, or the epithelial cell system 
has less and less power to resist a second 



invasion. 



This is an interesting field for inquiry. 
I will here suggest what appears to point 



DIPHTHERIA AND SCAR.IET FEVER. 



423 



in this direction, and which may be found 
on careful and extended research to be the 
true cause of this susceptibility to a second 
invasion. 

The parent epithelial cells are to a consid- 
erable degree permafient and independent or- 
ganisms. Each has its attachment, and car- 
ries on its own organic processes, more or less 
independent of its neighbor. These parent 
cells are the bodies through which fever poi- 
sons gain access to the system. They are the 
bodies that are deranged in their organizing 
functions by fever poisons, and the organisms 
that 7?iust receive the more or less permanent 
prophylactic or resisting impress. This im- 
press, upon any given epithelial cell, is no 
doubt permanent. It has been observed, and 
I have 710 doubt of its truth, that these parent 
epithelial organisms from time to time, and 
from a variety of causes, die, disintegrate and 
disappear, while new parent cells develop to 
take their place. 

In process of time, varying greatly in dif- 
ferent persons, a great share of ihe original 
epithelial cell structures that had at some pre- 
vious period received from an invasion of one 
of this class of diseases a protective impress, 
may have passed away, and a new system of 
epithelial cells taken their place. This new 
system of epithelial cells, having never been 
invaded, are, of course, like the first, suscep- 
tible of invasion, and in such case there- would 
be a second attack of the disease in the same 
individual. This attack would vary in inten- 
sity with the proportion of new epithelial cells 
in the glandular surf ace (each epithelial cell 
may be regarded to all intents and purposes a 
glana). If there are but few, the tende?icy 
to the second attack would be very slight — so 
slight that it would not be attended with any 
eruption, and with but slight febrile symptoms. 

This is what every physician has often 
noticed in his own case, when attending 
upon contagious fevers. 

I trust the investigations and few re- 
marks here offered will interest the serious 
consideration of medical observers in this 
interesting field of inquiry. 

I am satisfied that careful observation of 
the epithelial cell organisms, the study in 
detail of their ultimate and all-important 
functions, will not only be highly interest- 
ing to the observer, but will inspire him 
with that confidence he has seldom before 
felt, that his researches are now in the way 
of ultimate and important physiological and 
pathological truths, the solution of which 
has resisted past research, and which are 
destined to remove many remnants of em- 
piricism from the healing art, and reduce it 
more to a science of unvarying principles. 



It is only by the study in detail of this 
organizing cell system that we may expect 
to discover those primary and ultimate 
physiological and pathological actions and 
medicinal effects which lie at the very 
foundation of all healthy, diseased and cura- 
tive processes. 

Resume. — The following* is a brief sum- 
mary of the facts and inferences which ap- 
pear to be indicated by the foregoing in- 
vestigations. 

i st. — That the disease occurring near 
Lancaster, Ohio, here described, and which 
proved so fatal, is Angina Maligna. 

2nd. — That Angina Maligna is a conta- 
gious disease. 

3rd. — That Angina Maligna is closely al- 
lied to Scarlatina Anginosa and that diph- 
theritic diseases generally are allied to those 
of the scarlatina type. 

4th. — That the primary seat of the dis- 
ease in both scarlatina and diphtheria is 
the epithelial cells. That these are so de- 
ranged in their functions by the morbific 
cause of the disease, that the nutrient pro- 
ducts which they organize become so 
poisoned that they poison the tissues they 
are designed to nourish. This poisoning 
takes place during the period of incubation. 

5th. — That morbific poisons cannot enter 
the system without first passing through and 
primarily deranging the epithelial cells and 
their products; as these cells envelop the 
entire organism, and guard all the ap- 
proaches to it. That they affect the tissues 
by poisoning the organized matters which 
go to their support. 

6th. — That the epithelial cells of mucous 
and serous surfaces assimilate and organize 
all the nutrient matters which go to build 
up and support the tissues. 

7th. — That the perceptible symptoms of 
these diseases are but expressions of the ef- 
forts of nature to eliminate from the system 
the morbific poison. 

8th.— That the exudations of the mucous 
surfaces in diphtheria are produced by the 
too rapid metamorphosis of mucous cells in- 
to filaments, which filaments become woven 
together, forming a felt-like membrane, be- 
fore they are fully liberated from the follicles. 

9th. — That the tendency to filament me- 
tamorphosis in diphtheria is general 
throughout the epithelial system, showing 
that it is a systemic disease. 

1 oth. — That the Mucor Malignans appears 
to be the primary cause of Angina Maligna, 
and of Angina Membranacea. That the 
diseases are specifically the same, the dif- 
ference being caused by the state of the 
system in the person attacked. 



424 



DIPHTHERIA AND SCARLET FEVER. 



nth. That as the tendency is for the 
cells to become developed into filaments 
and resultant membranes before they are 
fairly out of the follicles, the object of any 
treatment should be to retard this filamen- 
tous development and promote the secre- 
tions, so that the cells may escape before 
they become filaments, also to check the de- 
velopment and to destroy the fungoid cause. 

1 2th. — When the filaments are strong and 
membranes tough and adhesive, mercurials 
should be resorted to, to soften the threads 
and render exudation less adhesive. 

13th.'— That these diseases are but the ef- 
forts of nature to eradicate from the system 
morbific matters, that it should be the con- 
stant care of the physician not to run coun- 
ter to nature in the efforts to cure the vi- 
tiated condition of the organism, but sim- 
ply to endeavor to destroy the cause, and 
so to equalize, aid and modify her actions 
as to alleviate suffering, facilitate her pro- 
cesses, and guard against dangerous re- 
sults. 

14th. — That it is a normal action for the 
cell products of epithelial cells to become 
gradually metamorphosed into filaments. 

15 th. — That if by any cause the metamor- 
phosis prematurely commences and the 
process is accelerated, it becomes a patho- 
logical action, which tends to result in grave 
abnormal conditions. In epithelial tissue 
there result membranes, exudations, and 
clots; in connective tissue, the various can- 
cerous and fibrous growths. 

1 6th. — That the epithelial cells have a life 
independent of the animal, all the external 
and internal surfaces of which they envel- 
ope and protect. 

17 th. — That they appear to be the primary 
seat of the functional derangements in all 
true fevers. 

1 8th. — That they are the probable organ- 
isms which receive the protective immunity 
by one attack of certain contagious dis- 
eases that tends to guard the system against 
a second invasion of the same. 

19th. — That in health it would seem that 
neither nutrient, medicinal nor morbific 
agents can enter the system so as to nourish, 
medicate or vitiate the tissues of the organ- 
ism, without first passing through the cells, 
and imparting a primary influence to them 
and the products they organize. 

20th. — That it is probable that morbific 
matters poison the tissues of the body 
through the nutrient products organized for 
their support by the epithelial cells. 

2 1 st. — That local fever of the mucous 
surfaces may be excited at will by exposing 
them for a few minutes to contact with the 
32 West 26th St., June, 1882, 



spores of certain algae and fungi that devel- 
ope upon ague bogs, old straw, &c. 

22nd. — That it is probable that by con- 
tinued exposure to these and similar causes 
(the taking of spores into the system through 
the food eaten and the air inhaled), that 
febrile action over the entire epithelial sur- 
faces, including those of the lacteal and 
lymphatic systems, would be excited, in 
which case general fever would result. 

23d. — That the altion of the " fever poi- 
son " upon the nervous system is through 
the nutrient nerve products organized by 
the vitiated and functionally deranged epi- 
thelial cells, and hence is a secondary pro- 
cess or manifest symptom of the primary 
functional derangements of these epithelial 
cell organisms, or of the ultimate disease. 

24th. — That the treatment should be 
prompt and direct, aimed not only at the 
destruction of the cause, but at the removal 
of all the pathological conditions and states 
which this cause has excited. 

The Mucor Malignans should be checked 
in its development and destroyed, and at the 
same time the toughness and adhesiveness of 
the exudations should be softened, the chok- 
ing and suffocation should be relieved, and 
the throat, fauces and air passages be kept in 
as comfortable a state as possible. To de- 
stroy the cause, quinia sulphate — all things 
considered — is the best and most reliable 
remedy, as it braces up the enfeebled sys- 
tem while it is destroying the fungus. 

It is not enough to give it every two hours 
or every hour, but it should be administered 
every half hour, and in some instances per- 
haps even oftener. It should be given in 
powder, so as to keep the throat and fauces .? 
constantly covered with it, and if necessary 
it should be snuffed and inhaled into the air 
passages. To destroy the toughness of 
the filaments and the adhesiveness of the 
membranes, small doses of mercurial often 
repeated are useful. To relieve the chok- 
ing and suffocation, the simple hop poul- 
tice, applied as hot as it can be borne 
around the neck, and so covered as to allow 
the steam from it to be inhaled, is a very 
effectual relief. Also small doses of sul- 
phuric ether in coffee, or the inhaling of a 
few drops of nitrate of amyl, may prevent 
sudden suffocation incases where the phy- 
sician is called in the last stages, and 
through these precious time may be gained 
for using vigorously the quinine. 

In conclusion, I take pleasure in express- 
ing my obligations to Drs. Boestler, Effinger 
and Lewis, who have felt interest in my la- 
bors, and to whom I am indebted for much 
excellent material in these examinations. 



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DESCRIPTION OF PLATES. 

Amplification 2500 diameters and over. 



Plate ist. Forms found in the expec- 
toration and exudations of diphtheria. 
A-S-T — Healthy buccal mucous cor- 
puscles—page 409. B-C-H-I — Mucous 
corpuscles from Amos Bear's mouth, show- 
ing the spinning of filaments in diphtheria. 
D-E-M — Mucous cells connected with fila- 
ments. E — A row of mucous cells. F— mu- 
cous cells spun into a long branched fila' 
ment. G. — Sporangia of sphaerotheca py- 
rus — found also in pear blight. H-I-K-M- 
N-0 — Mucous cells from Nancy Bear. 
U— Automobile microspores — the bacteria 
and micrococci of authors. P-Microspores 
found in Q and R. Q-R — Membrane in diph- 
theria. W-Membranous vegetable sac found 
in urine of scarlet fever, placed here for con- 
venience. Z — Three cells in active filamen- 
tation. 

Plate 2D. Fig. 2. Bodies found in the 
sloughs of Amos Bear. Diphtheria. A — Em- 
bryonal form of vegetation — the bacteria 
and micrococci of writers — page 410. B-C-D 
— Mature mycelial filaments, running in all 
directions through the sloughs. E-F-G-H — 
Spores and microspores of the mucor ma- 
lignans. I — Ascus. K-P — Spores of apple 
blight — sphaerotheca pyrus. M-N-0 — 
Spores with mycelial filaments do. U-V-W 
— Large mucous cells with entophytic fungi. 

Plate 3. Fig. 3. — The mature plant of 
diphtheria developed by culture. — page 411. 

Mucor Malignans. — A-Fertile plant of 
Mucor Malignans with three clusters of 
sporangia. B — Plant with erect filament and 
undeveloped fruit. C-D-E — Stroma or mem- 
branous net work of mycelial filaments 
dotted over with microspores. W — Micro- 
spores that fill the sporangia at A. G-M- 
N-S-T — Automobile spores, some arranged 
into filaments. U — Collection of mature 
sporangia and filaments matted together as 
in the membrane. V — Separate mature spor- 
angia. 

Plate 4. Fig. 4. — Abnormal morpholog- 
ical elements found in the blood of diph- 
theria and scarlet fever. A-B — Masses of 
colorless corpuscles filled with embryonal 
forms (spores) of the mucor malignans. C- 
C — Amoeboid projections of protoplasm do 
do. D — Automobile microspores more 
highly magnified. E — Caudate cells like I 
and B, Fig. 1, PI. 1. F— Endothelia of 
blood vessel with entophytal vegetation es- 
caping. G — Colorless corpuscles forming 
into a filament. H and K — Skeins of my- 
celial filaments in the blood. M-N — Fibrin 
masses enclosing mycelial filaments. I — 
Filament resembling neurine — page 413. 



Fig. 5. — Crystalline bodies found in the 
blood of scarlet fever and diphtheria. A- 
B-C-D — Uric acid. E-K — Peculiar forms 
do. I — Urates of soda and ammonium. 

Fig. 6. Plate 5.— Forms found in urine 
and sputa of scarlet fever and diphtheria. 
B — Mycelial filaments found in sputa of 
diphtheria. F-G — Filaments from urine of 
scarlet fever. H - R — Leptothrix with 
anabaina. M& M 1 — Structureless mycelial 
filaments — urine of diphtheria. A — Anguil- 
lila aceti from vinegar gargle of Amos 
Bear. Q-Q 1 — Cells uniting to form fila- 
ments. C — A knot of mycelial filaments 
such as are found scattered over the mem- 
branes of angina malignans. L-S-T-U-V- 
W — Embryonal spores and filaments more 
highly magnified. — The bacteria and mi- 
crococci of authors. X — Mycelial filaments 
such as also occurred in vast numbers in 
ripe persimmons in Ohio, 1862. 

Plate 6. Fig. 7. — Bodies found in the 
excretions of scarlet fever. A — Normal 
mucous cell. B-C-H — Mucous cells (scar- 
let fever), in an active state. D-E-L-M-I — 
Do. Do. in active filamentation. See also 
Z, Fig. 1. Plate 1. G — Mucous cell with 
micrococcus spores escaping at end of fila- 
ment. N-O-near A — Do. Do. arranging 
themselves into rows to form filaments. 
P-Q — Mycelial filaments of mucor malig- 
nans. R — Moniliform filaments formed and 
forming. S & T— Highly refractive spheroi- 
dal cells of reddish orange colored fila- 
ments in cell on right. U — Alcholic yeast. 
V-Vi-W— Cells shedding contents. V-X-Y- 
Z-N near Z — Contents more highly magni- 
fied. 

Plate 7, Fig. 8. — Bodies found in urine 
of scarlet fever. A, B, C, sporangia of mu- 
cor malignans. D, parent epithelial cells 
from bladder. E, mycelial filament, I, K, 
L, N, near B, species of hypheothrix. O r 
uric acid. R, R, R, creatine. S, T, U, 
(N should be U) other forms of uric acid. 

Fig. 9. — Scarlet fever. A, B, C, dermal 
epithelia cultivated. D, micrococcus spores 
from epithelium. E, F, K, ditto, united in 
moniliform filaments. G, H, ditto, united 
by twos and threes. L, diatom from drink- 
ing water. M, filament of spores united 
by twos. N, Q, Epithelial cells of skin 
of scarlet fever. O, P, abnormal spor- 
angia of mucor malignans, both broken. 
R, long tubular mycelial filament. All 
these were automobile like oscillatori- 
acae. S, S, central nuclei of N and Q. T, 
patch of membrane with mycelial filaments 
of mucor malignans curiously twisted to- 
gether and curled. U, urate of soda. W, 
barb of feather. X, phosphate of lime. 
Y patch of membrane. 



LIBRARY OF CONGRESS 



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